Episode 19: Burns Part 1
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Stuart Watson
08/08/18
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Guest Bios
Stuart Watson
Mr Stuart Watson is a Consultant Burns and Plastic Surgeon at the Canniesburn Unit in Glasgow Royal Infirmary, as well as a Director of ReSurge Africa. He is also one of the european representatives on the Executive Committee of the International Society for Burn Injuries (ISBI) and a member of the steering group of the ISBI developing international guidelines for care of burn injuries.
Show Notes
Eoghan and Stuart discuss the management of burn injuries including pre-hospital care, emergency management and follow-up. In this episode they cover all uncomplicated burns (from superficial to full-thickness) including first-aid, analgesia, dressings, blister debridement and when to consider surgery..
Take Home Points
PREHOSPITAL CARE
Remove from scalding agent and remove clothing
Small burns:
20 minutes of cool running water on burn
reduces depth of burn and excellent for pain relief
can do at home if no urgency to get to hospital
Larger burns:
brief cooling for 1-2 minutes to avoid hypothermia (especially kids and older adults)
then cool soaked cloths on the burn and can replenish the water
Room temperature water is good but a little colder is better
Avoid ice (can cause additional tissue damage)
DEPTH OF BURNS
Erythema (1st degree)
sunburn and scalds
skin unbroken but red/inflamed and often very painful
needs cooling and analgesia but doesn't require fluid resuscitation
Superficial partial thickness (2nd degree)
epidermis is blistered off
has a bright pink/red/inflamed and moist surface
blanches on pressure (circulation is intact)
looks superficial and skin is alive and healthy
Deeper partial thickness or deep dermal (2nd degree)
has fixed staining (no blanching)
varying colours such as white, orange or red
takes a longer time to heal and often will benefit from surgery
Full thickness (3rd degree)
leathery appearance (look and feel)
dry, hard and inelsastic
NOTE: some flame injuries can be white and hard to tell from normal skin
MANAGEMENT
All burns:
Ensure comfortable
Good history of how it happened
try to identify what the burning agent is
Good ABCDE assessment and always exclude other potential injuries
Consider NAI in kids
If not had any first-aid then apply it now
Erythema (1st degree)
Apply cold running water (20mins) and assess if skin broken or not
Analgesics: standard WHO guidelines (paracetamol, weak opiates and ibuprofen)
Dressings:
typically leave undressed
could cover if likely high-chance of abrasion (e.g. across a major joint)
could use a non-adhesive dressing (e.g. paraffin gauze or silicone-based dressing)
if on face - hydrogel dressings ca be excellent at relieving pain
Discharge advice:
keep out of sun and drink fluids
elevate and rest burned limbs
skin tends to dry so could use a simple (fragrance-free) moisturiser after a few days to avoid dryness and easy comfort
No follow-up typically required
Superficial partial thickness (2nd degree)
Blistering:
strongest evidence is to remove blistered skin
they can get larger and more uncomfortable, or
they can burst and the dead skin is a breeding ground for infection
give them analgesia in advance (cocodamol for adults or diamorphine IN for kids)
Analgesics:
20mins of cooling
standard WHO guidelines (paracetamol, weak opiates and ibuprofen)
face - hydrogel dressing is a good choice for pain relief
Dressings:
NOTE:
children have a small but significant risk of life-threatening (toxic shock) infection, even in small burns
these burns tend to have signifiant exudate leak over the first 24-48 hours
Basic Emergency Management:
ADULT:
inexpensive, gelonet dressing, covered with an absorbent gauze and held in place with a bandage
bigger areas may benefit from topical antiseptic (as for children)
in the perineum or perianal areas then a silver-based cream (such as Flamazine) is useful
CHILDREN:
minimise risk of toxic-shock syndrome
silver-impregnated dressing such as Urgotul SSD, or
jelonet/mepitel non-adhesive, with mupirocin underneath, and gauze/bandage on top, or
inadine dressing with gauze and bandage on top
Follow-up within 24-48 hours
Practice nurse if uncomplicated
Secondary care if complicated (burns nurse or dressing clinic):
arger (e.g. >1%), children/elderly, complicated injuries (joints, face, feet, perineum etc)
reevaluate the depth/size of burn
all burns have a great capacity to change depth and extent in first 5 days
check for signs of infection
unlikely to have overt infection within 1-2 days but might be developing subtle signs
consider a wound swab if 'not quite right'
change of dressing
these burns produce a lot of exudate which needs changed at 24-48 hours
could then switch to a hydrocolloid-type dressing
create a moist wound-healing environment to optimise speed of healing
not suitable initially due to exudate (change to this at 1st or 2nd visit back)
also have a lower adherence to wound than jelonet or mepitel
Deep Partial thickness or deep dermal (2nd degree)
Generally the same first-aid principles apply
NOTE: main concern is the greater risk of a poorer functional or aesthetic result
is it likely to take longer than 3 weeks to heal (and avoid a thick/hypertrophic scar)??
>2cm (or any size in child) - best to refer
if tiny then look after for 10 days (reassess every 2-3 days) and refer then if not progressing
in-between = use judgement
Full thickness (3rd degree)
Similar basic first-aid but generally less painful when occurred
Start thinking 'could it be more complex'
can be '4th degree' = damage to deeper structures
generally dead, dry and tight and has tendency to constrict acting as a tourniquet
therefore: check distal neuromuscular function in limbs and ensure airway ok in face/neck injuries
Refer all patients with full thickness burns for consideration of surgery
they will heal faster, with less risk of infection and less likelihood to develop thick, hypertrophic scarring
remember there will still be a scar after surgery
if very small (or patient unfit for surgery)then could offer to dress and monitor
WHAT HAPPENS TO FULL THICKNESS BURNS (that are not operated on)
dressed for a few weeks with a dressing that softens the dead skin which will lift off over several weeks
this will leave an equivalently-sized area of granulation tissue underneath
the wound is vulnerable to infection during this period
large open wound
big patch of dead tissue on top that is a breeding ground for infection
when dead skin sloughed off then wound will gradually heal from the sides by contraction
high-risk of severe contraction at joints with impaired function
High risk of hypertrophic scar
delayed healing (>3 weeks) stimulates production of collagen protein in the care to an excessive degree
THE PROBLEM WITH JOINTS
NOTE:
burn injuries restrict movement during healing and impede function
after healing scarring can cause contracture which interferes with function
generally dressed with joint extended
if any doubt then involve physiotherapy to asses ROM and provide exercises to optimise ROM
if slow to heal then liaise with surgeon to consider benefits of surgery in first 2 weeks
burn that takes >3/52 to heal has an increased risk of becoming a thick, hypertrophic scar